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Friday, 28 August 2015

In this month's blog post Peter Reid, MLitt research student at the Centre for the History of Medicine in Ireland (CHOMI), UCD, looks at the treatment of shell shock in Ireland during the Great War. He argues that the formation of a rational medical service for these soldiers in Ireland was undermined by the antagonistic relationship between military and civilian medical authorities.

On 22 July 1929, John Kelly, an ex-British soldier, fell from a window of his residence in Dublin's Queen Street and later died from his injuries while being treated at the Richmond Hospital. His wife did not witness his fatal fall, but said that her husband, 'had been in ill-health since his discharge from the army in 1919, suffering from paralysis and shell shock.1

Until recently, there had been relatively little research undertaken on the management of shell shock in Irish institutions during the Great War. In the case of Britain, Peter Leese has shown that army and military concerns dominated over those of civilian medical experts.2 This post argues that a similarly asymmetrical relationship between asylum and military medical personnel was one of the key factors inhibiting the development of a well-coordinated shell shock treatment system in Ireland.

The Irish War Hospitals

The Richmond War Hospital, 1916-1919.
Image provided courtesy of the
National Archives of Ireland.

In Britain, by 1916, demand had overwhelmed the capacity of treatment facilities for shell shocked soldiers. From the summer of that year, the first treatment centres in Ireland, which would include two war hospitals, began to open in the main urban centres of Dublin and Belfast. The first of the war hospitals, a thirty-two bed unit, the Richmond War Hospital, received its first patients in June 1916. This hospital was a separate block within the grounds of Dublin's Richmond District Lunatic Asylum, allocated by the asylum's board of governance for this purpose. It admitted only British Expeditionary Force soldiers, that is, those soldiers who had served overseas at the Western Front. The main Richmond Asylum itself, however, admitted non-British Expeditionary Forces - the home troops. The army paid a generous stipend to the Richmond Asylum for the care of both categories of soldier.

Belfast District Lunatic Asylum.
Image provided courtesy of the National Library of Ireland.

In response to rising casualty numbers, the civil and military authorities agreed to relocate existing patients from the Belfast District Lunatic Asylum and use that facility as another war hospital. The Belfast War Hospital opened in May 1917 under the management of the existing District Lunatic Asylum Committee. It provided 500 beds for the use of both expeditionary and non-expeditionary British service personnel. Dr William Graham, the Medical Superintendent of the Belfast Asylum, remained in place as the medical authority running the new war hospital.

The evidence suggests that Dr William R. Dawson, already a leading figure in Irish medicine and highly regarded by the British army, played a key role in facilitating, if not initiating, both arrangements.

William R. Dawson, appointed by the War Office in 1915,
as a specialist in nerve disease to treat British service personnel in Ireland.
Image provided courtesy of the Royal College of Physicians of Ireland.

The Resident Medical Superintendents and the Royal Army Medical Corp

Tensions in the relationship between the Richmond Asylum's Medical Superintendent, Dr John O'Conor Donelan, and his military counterpart, Lieutenant Colonel Hearn, Officer in Charge, George V Hospital, Central Military Hospital Dublin, quickly became apparent. Hearn instructed Donelan by letter that as Officer in Charge of Central Hospital that he, Hearn, was ultimately responsible for all soldiers in the asylum, 'until such time as they are invalided out of the army'.3 Three days later, Hearn again wrote to Donelan and firmly reiterated the point that 'should a man in your opinion require to be moved to the General Asylum [from the Richmond War Hospital] he still remains a soldier until finally discharged from the service by recommendation of the Military Board'.4

The army's insistence on reserving the use of the war hospital solely for expeditionary soldiers, on prioritising their treatment over that of non-expeditionary soldiers, on maintaining their control over the admission and discharge of all military patients, and the complex bureaucratic needs of the military machine, served to insidiously undermine Donelan's authority. Donelan's dissatisfaction with the arrangement is evident in his asylum report of 1917 when he bemoaned the high number of discharges 'classified as only relieved'. He attributed this to 'the fact that a considerable proportion of these were soldiers under temporary treatment, who were removed by the Military Authorities to other asylums before recovery'.5 Donelan was implicitly criticising the military authorities for prioritising the needs of the army over the professional opinion of asylum medical officers, in particular himself.

When the Belfast War Hospital opened in May 1917, it was initially managed by the existing District Lunatic Asylum Committee. However, as Lieutenant Colonel J.B. Buchanan, Officer-in-Charge of Holywood Military Hospital, noted in 1919, 'this plan did not prove satisfactory'. When the Resident Medical Superintendent, Dr William Graham, died suddenly in November 1917, the Belfast War Hospital came under the direct control of the War Office.6

Consequences of an unsatisfactory relationship

Between 1916 and 1919, the Dublin and Belfast Irish war hospitals treated 1,577 soldiers. However, there were never enough beds in Ireland for emotionally traumatised soldiers such as John Kelly and, by 1921, the 'South Ireland Pension Area' - Ireland exclusive of the province of Ulster - had the longest waiting list in Britain and Ireland for treatment.7 The antagonistic relationship between medical and military actors was one factor contributing to this unfortunate situation.

Contemporary relevance

In a report issued in July 2015, the Mental Health Commission identified that a lack of cohesion and 'deep disharmony' between clinicians and managers had undermined clinical governance in Carlow/Kilkenny and South Tipperary and, in early 2014, was associated with a 'spike' in suicides in the region.8 This reflects the continuing importance not only of independent surveillance by bodies such as the Mental Health Commission and the Health Information and Quality Authority, but also of managerial and clinical relationships in the delivery of contemporary mental health services in Ireland.